Bernie Lim Consultant Maxillofacial Surgeon

Third Molars

Overview
Development of third molars Indications for removal of third molars Contraindications for removal of third molars Surgery and perioperative care Expected postoperative course Complications of surgery Question time

Third molar development

9 years: radiographic appearance of tooth ger m 11 years: tooth with cusps mineralised located anterior border of ramus with occlusal surface directed almost entirely mesia lly 14 years: crown formation complete 16 years: root formation 50% Mandibular growth continues and the tooth ass umes position at the root level of the adjacent 7 18 years: completed root formation with open apex 24 years: 95% of teeth that are to erupt have d one so

Impaction
Most 3
rd

molars become impacted

Ascending ramus 48 47

Impacted versus unerupted teeth (arch length disc repancy) 50% of impactions are mesoangular The nature of the impaction is thought to be relate d to differential development of mesial and distal roots Laterally positioned teeth impact against the exter nal oblique ridge Third molar developmental delay may also result in impaction Most third molars have erupted by 20 years The position of third molars will not change signi ficantly after 25 years

Indications for removal of imp acted 8s

1) Pericoronitis:
Peptostreptococcus, Fusobacterium and Bac teroides Mild to severe Management
Debridement Extraction Antibiotics? Operculectomy?

2530% of 8s are removed due to pericoronitis

2) Prevention of dental disease

Caries in the 7 or the 8 account for around 1 5% of extraction cases Periodontal disease (5%), with periodontal pocketing, attachment loss, and inflammation

3) Orthodontic considerations
Crowding of mandibular incisors
A contentious issue; while impacted 3
rd

molars are likely to contribute to dental crowding, the etiology of crowding is complex and multifactorial

Obstruction of orthodontic treatment Interference with orthognathic surgery

Plan for removal at least 6 months prior to surgery Some clinicians are not too concerned

4) Prevention of odontogenic cysts and tumours

The follicular sac surrounding 8s can give ri se to pathology
Dentigerous cyst Odontogenic tumour Malignancy

12% of 8s are removed due to concurrent od ontogenic cysts and tumours Pathology is usually seen in those less than 40 years of age

5) Root resorption of adjacent teeth

Extract the 8 ASAP 7 will repair itself unless damage is so sever e that it necessitates removal

6) Pre-prosthetic
If the unerupted tooth is covered by less tha n 1-2mm of bone or mucosa only, it will eventually be exposed under a partial p rosthesis In those over 40 years, with no pathology a nd adequate bony encasement, the tooth may be left in situ

7) Prevention of fracture
Contact sports